Intended for healthcare professionals

Career Focus

District general hospital or teaching hospital?

BMJ 1999; 318 doi: (Published 20 February 1999) Cite this as: BMJ 1999;318:S2-7182

William Sellar discusses some considerations when selecting where to apply for a consultant or career grade appointment

  1. P W Sellar, consultant ophthalmologist
  1. Department of Ophthalmology, West Cumberland Hospital, Whitehaven

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    After at least four, and probably more, job changes since passing out through the doors of medical school, you may be ready for some stability in your nomadic medical career. This will be especially so if you have a family that has, willingly or otherwise, been displaced from hospital accommodation or a rented home on a number of occasions, each time meaning lost friends and adjustment to new schools and circumstances. The prospect of a final move into a permanent job and the chance to settle down is usually quite a relief; it is an opportunity not to be wasted, but also not to be rushed. The only problem is that jobs come up suddenly, and, once taken, there may be no new vacancies in a specific area or subspecialty for many more years, so decisions need to be made quickly.

    As with buying a house, which may also be required in the process of taking up a consultant post, knowing what you want is helpful. As every despised estate agent knows, three important points should be borne in mind: location, location, and location. However, having an open mind about places that you might not have immediately considered is also wise, especially if your specialty is oversubscribed. The following points may help you assess what you want or can expect from a job location and highlight the advantages of the humbler district general hospital compared with the often overrated advantages of a teaching hospital.

    Personal considerations

    Easy access to elderly parents or other dependent relatives may be important, but such dependants may be happy to relocate near you. A spouseõs job may also seem to be fixed, but many employers can offer relocation possibilities. If your partner also works in the health service, it may be well worth inquiring informally, before an interview, about his or her prospects if you were to be appointed to a new location. Spouses often add to personal concerns over a relocation by worrying about apparently mundane things such as not having easy access to familiar big city shopping chains or old friends. A joint visit before the interview is therefore wise to dispel misapprehensions and to allow you to discuss an area, so that you go to an interview with the confidence that you really want the post and would accept it if offered.

    Couples with “no children yet” often overrate city locations and fail to recognise the advantages of a more rural position for raising children. City cinemas and restaurants become an occasional luxury once kids arrive. Good schools can be found in most locations. Advantages of more rural areas include less congested travelling to work, often cheaper housing, easy access to beautiful scenery and outdoor pursuits, as well as possibilities for valuable involvement in a smaller community. Road connections in the regions are generally surprisingly good, but public transport is often disappointing. Regional airports and seaports offer excellent access to families or holidays overseas.

    Medical considerations

    Specialisation -Probably the most important consideration is whether you want or are capable of maintaining a highly specialised service or academic career after specialist training. Only tertiary referral units may offer enough patients with rare conditions to maintain a very specialised interest, such as cleft palate or orbital surgery, or offer laboratory facilities for unusual research techniques. If your intention is to climb the academic career ladder you may well do better applying for a university hospital consultancy. Some superspecialists have become so focused that they have lost contact with other subjects within their own specialty and rarely see common acute complaints. However, consultants in district general hospitals face less selected cases and need to be confident in dealing with a broad spectrum of clinical problems. There usually remains the possibility of having a broader specialty interest, such as diabetes or glaucoma, without abandoning so much of your general training.

    Research -Choosing a district general hospital does not necessarily mean having to give up the specific research interest that you carefully cultivated as a specialist registrar. Most district general hospitals now offer support staff for audit and research and have online search facilities in their postgraduate centres, as well as connections with local universities. District general hospitals also offer you the luxury of seeing your own patients again for follow up, allowing you to establish a more accurate database for a research interest than might be the case in a university hospital, where patients are often seen by junior doctors and lost to follow up. Remember that a district general hospital can no longer be considered an escape from research as, increasingly, clinical governance will require audit even in smaller units.

    Teaching -Some hospital doctors still assume that a sign of having made it to the grade of consultant is to have a hierarchy of trainees in tow. This rather fanciful idea is the stuff of teaching hospitals, but moving to a district general hospital does not always lead to loss of responsibility for teaching.

    Many district general hospitals have junior doctors, specialist nurses, paramedics, and general practitioner registrars, whose teaching requirements are often more challenging than those of the ubiquitous medical students and trainees found in teaching hospitals. Regional postgraduate courses and general practitioner training programmes also offer scope for involvement in teaching.

    Out of region -A move to another region can give feelings of insecurity, but quickly establishing contact with colleagues who offer support for subspecialty problems may help alleviate such concerns. Your special interest may also be highly valued in another region, giving you opportunities to broaden contacts with another academic centre. Personal origins in an underserved region may also motivate you to return to serve the local population and help redress the gravitation of professionals to the big cities.

    Competition -Large city jobs are often more hotly contended than those in peripheral district general hospitals. The reasons are several but seem to include a widespread reluctance to seriously consider the unknown and a preference for the security of the familiar, which for most specialist registrars will be a large teaching hospital. You may imagine being isolated in a small district general hospital that you have never visited before. Often rumours about a certain peripheral hospital or unit are rife but are unsubstantiated or now historical. A well planned visit before an interview will often dispel worries in this respect. Besides, your presence in such a unit could help to turn a demoralised department into one that has direction. Recognise, too, that nowhere is perfect-and certainly will not be if you decide to join them.

    Locums -Since some district general hospitals have problems attracting consultants, there may be locum posts on offer. These are often an excellent opportunity to try out a hospital department to see how you fit. Having been a popular and successful locum is a great advantage when you apply for a substantive post, and both you and your prospective colleagues will be more assured about your ability to fulfil a role in their team as you approach an interview.

    Peripheral hospitals -With fewer consultants, on call commitments in district general hospitals are often more frequent but less intense than in large cities. With fewer, if any, junior doctors, you may also be required to take a more hands on approach, accepting general practitionersõ calls or doing more spinal taps or cyst removals than you would expect to in a teaching hospital, where consultants are often protected by extensive casualty services, acute referral clinics, and senior house officers. Attendance at regional meetings may, however, be a problem because of travelling distances, but telemedicine is now presenting the possibility of joining in postgraduate meetings from a distance, as well as offering the chance of obtaining advice or reassurance about an uncertain diagnosis. One advantage of the smaller numbers of consultants in a peripheral hospital is that your opinion, in the choice of new equipment or other developments within the unit, may count for more than it would in a large, heavily staffed teaching hospital.

    Private practice -If you intend to make lots of private income you might do best to pick a south coast location or the stockbroker belt. However, if you have family, church, or leisure priorities for your limited free time you may be better off in a lower income area without such great temptations from private practice and the subsequent need to absolve yourself of part of your NHS contract. A more northern or western location in Britain may have lower living expenses than the London area, and a cheaper house could allow you more disposable income for those skiing holidays or school fees without your having to carry out private practice.

    ConclusionIt is said that no marriage is perfect, but that with some love and a little determination you should still be happy for the rest of your life. The same is true of a consultant post. Bearing in mind the considerations above, and no doubt some personal ones, you should be able to find a location that suits you and your family. With a love for your specialty and some effort to appreciate the advantages of a new location, most consultants will never move again during their careers.

    What you can offer and what do you want?

    • Academic career or generalist?

    • Subspecialty skills and vacancies?

    • Research interest or just audit?

    • City preference or rural interests?

    • Family's preferences and hobbies?

    • Access and commitment to relatives?

    • Private practice or life outside the NHS?

    • Check for locum opportunity or just take a chance?